Release Of Medical Information printable pdf download

Medical Records Office

5 Lower Kent Ridge Road

Kent Ridge Wing 2, Level 1

Singapore 119074

Tel: (65) 6772 5163 / 4776 / 5233 Fax: (65) 6777 3295

Email:

MedicalReportSection@nuhs.edu.sg

Co. Reg. No. : 198500843R

RELEASE OF MEDICAL INFORMATION

Instructions:

This form must be fully completed and signed by the patient. If patient is below 21 years of age, the form should be signed by the patient’s

parent/legal guardian.

For interested third parties: Patient’s consent is required. If the patient is deceased, a copy of the patient’s death certificate and the consent of

patient’s estate are required.

The completed form must be submitted with payment of the fee (if applicable and as indicated below). Cheque payment (when applicable) should

be crossed and made payable to “National University Hospital (S) Pte Ltd”.

The release of medical information is subject to official approval.

PATIENT PARTICULARS AND CONSENT

Patient Name: ____________________________________________________________________________

__ Gender : F / M

NRIC / HRN: _____________________________________

__ Contact No.:__

________________________________________

Mailing Address: ______________________________________________________

____________________S(_____________)

Period of Attendance / Admission in NUH: _____________________

_____ Clinical Department: _______

_____________ _

Name of Attending Doctor:

I consent to the release of my medical information and/or medical records (including but not limited to my care and/or treatment plan) by NUH for the

purpose/s stated in the next section to:

Name of Company (including name of Person-in-charge) or Person:

_________________________________________________________________________________________________________________

Address (including Contact Details) of Company or Person:

________________________

I am agreeable/ not agreeable* to the release of HIV result (if applicable) to the above stated recipient. (*Please delete accordingly)

With regards to Medical Report (if applicable), I undertake to pay any additional charges such as X-ray or laboratory charges which may be incurred in

the preparation of a medical report.

PURPOSE FOR RELEASE OF MEDICAL INFORMATION



For informing Employer/Next-of-kin* who will be responsible for the settlement of medical expenses incurred

Please delete accordingly

)

For generating the following medical report/letter/certificate, please select one of the following:

INSURANCE (To attach form)

CONTINUITY OF CARE

New Insurance Application (Code : 0950003, Fee : $80.25)

Referral from existing attending doctor (No charge)

Disability Claim (Code : 0950001, Fee : $180.20)

Self referral to another doctor (Code: 0950003,Fee: $80.25)

General Claim (Code : 0950003, Fee : $80.25)

Diagnosis / Procedure & ICD10 Code (Code: 0950002, Fee :

SPECIFIC REQUEST

Referral Letter / Discharge Summary (No charge)

$21.40)

Lab Result / X-Ray Report (Code: 0950008, Fee: $5.35)

Medical Certificate (Code: 0950007, Fee: $10.70)

PERSONAL

New Employment (Code : 0950003, Fee : $80.25)

Therapy Report (Code: 0950003, Fee: $80.25)

Legal Proceedings (Code : 0950006, Fees : $180.20)

Others (Please specify):

Second Opinion (Code : 0950010, Fees : $267.50)

_______________________________________________

For Non NUH Patient only.

NOTE:

For cancellation of medical report requests, administrative charges will be imposed. Please call the Medical Records Office to enquire on the

status of your request before cancellation. Partial or full refund will be made depending on the status of the request. Cancellation will NOT be

allowed if doctor has already prepared the report.

PREFERRED MODE OF COLLECTION (IF APPLICABLE)

When completed, the medical information is to be:

Collected personally. To contact via the contact number stated above.

Posted to my mailing address as stated above by Normal / Registered Mail* (Please delete accordingly)

Posted to the address of the company or person as stated above by Normal / Registered Mail* (Please delete accordingly)

Collected by my representative with an authorization letter with the representative’s name and NRIC No. and a copy of his/her NRIC.

Emailed to this email account : ___________________________________________

_____________________________________

_____________

_______ _

Signature Of Patient/Parent/Legal Guardian/Legal Representative

Name & Relationship to Patient (if not patient)

Date

of Deceased’s Estate* (Please delete accordingly)

For Official Use Only:

Received Date:

Payment posted by / Date:

Report Completion Date:

MRO-FORM-GEN-003

R7-11-14

Release Of Medical Information

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